101 Uses for a Dead Journal

There used to be a wonderful cartoon series called 101 Uses for a Dead Cat, which led me 25 years ago to give a talk at a British Association for Psychopharmacology meeting entitled 101 Uses for a Dead Psychiatrist. That was back in the days when Psychopharmacology meetings were places of debate and the British Journal of Psychiatry was guaranteed to have something of real interest in every issue. Under a series of editors the Journal was so good that it still inspires affection in the likes of me and an older generation of psychiatrists – worldwide.

Perhaps as a legacy of those times, the British Journal of Psychiatry now runs an interesting little corner in which they invite authors to distill the essence of an issue into 100 words.

This isn’t as easy as it might sound. It’s like composing a haiku or limerick or tweet – if you’re not used to it, it takes time to get the balance right especially when they invite you to write 100 words on Psychiatry and the Pharmaceutical Industry, as they asked me 3 years ago.

After a lot of revisions, this is what I ended up with.

Little Pharma made profits by making novel compounds; Big Pharma does it by marketing. Doctors say they consume (prescribe) medication according to the evidence, so marketeers design and run trials to increase a drug’s use. They select the trials, data and authors that suit, publish in quality journals, facilitate incorporation in guidelines, then exhort doctors to practice evidence-based medicine. Because “they’re worth it”, doctors consume branded high cost but less effective “evidence-based” derivatives of older compounds making these drugs worth more than their weight in gold. Posted parcels meanwhile are tracked far more accurately than adverse treatment effects on patients.

As it turns out, here was a manifesto for RxISK before RxISK was a glint in anyone’s eye. The journal accepted it without demur.

But the climate had been slowly changing with the chill spreading from the heart out to the extremities as happens in the most serious conditions. The journal has been getting a lot less interesting. There are few people I know who confess to reading any of its seemingly evidence based pieces.

I had already had a problem when asked to do a book review – 300 words. Again difficult to distill the essence of an important and complex book like The Loss of Sadness into 300 words. I was pleased with the outcome but the journal wasn’t and approached someone else to provide a review. I thought about protesting but let it pass – this will be a future post.

I was then asked to review one of these in all probability ghostwritten evidence based pieces, an article comparing escitalopram and venlafaxine. This article had a heavy sprinkling of the flaws found in pharmaceutical company trials outlined in Ben Goldacre’s Bad Pharma. I pointed out a number of them and gave a view that the piece was close to worthless – but that the editor might try an interesting experiment. Why not ask the company to post the full dataset linked to this trial in exchange for the privilege of posting in the British Journal? He either never had the nerve to ask the company or else was rebuffed and nevertheless went ahead and published.

Then on September 20th came an invitation to write another 100 word piece – on Antidepressants. It took more than 6 weeks before something took shape. When it did after some polishing I finally felt happy.

Isoniazid, reserpine, imipramine, atropine, stimulants, benzodiazepines, antipsychotics, fluoxetine, ketamine – all have antidepressant credentials. The word coined by Max Lurie has lost meaning; it’s a basket for acronyms. Psychiatry was the first branch of medicine to have specialist hospitals and journals, the first to adopt controlled trials, rating scales, and guidelines. The antidepressants beckoned us toward clinical neuroscience but have led to myth, hidden data, ghostwriting, more lives taken than saved, womb to tomb consumption, and an increased incidence of “depression” from 1 per 1,000 to 1 in 5 of us. Knowing when not to prescribe is the greatest art in medicine.

The response was:

Dear David

Thank you, that’s excellent. I will show it to the Extras Editors for review and will get back to you with their decision.

A week later it was:

Dear David

The Extras Editor has reviewed your 100 words and is happy with it generally, but has some reservations concerning the phrase ‘more lives taken than saved’ – would it be possible to tone it down or omit it altogether? The Editor feels that 100 words is not a good place for a polemic and that we should present a consensus view held by the profession in general, which may not pertain to this particular phrase… One other thing is that all the drugs mentioned in the text but Prozac are referred to by their generic names, shall we call it fluoxetine for consistency?

I responded:

Dear

I can happily concede the switch from Prozac to fluoxetine but ‘more lives lost than saved’ is a completely evidence based position – I can provide all the data for this. It would simply not be possible to say the opposite. I didn’t think these pieces were aimed at giving a supposed consensus view – I had assumed they must inevitably be viewed as somewhat idiosyncratic.

[For the record the entirety of the placebo controlled trials database on antidepressants (over 100,000 subjects) shows an excess rate of deaths on antidepressants compared to placebo].

To which the reply on December 18th was:

Dear David

I hope you are well. I am afraid I don’t have good news regarding your 100 words on antidepressants. The Editors have deliberated further on whether to publish it and decided they could not, unfortunately, publish it in its current form. We are very sorry for this outcome and are grateful for your time and efforts.

Wishing you a Merry Christmas and a bountiful New Year.

Almost anyone I know who goes to the United States these days is astonished by the level of fear there among anyone working in the mental health field – fear to express any criticism about drug therapies, a fear to lower doses, or reduce treatment cocktails from 5 or 6 drugs to 1 or 2. The land of the free and home of the brave seems anything but these days.

Things feel better than this in Britain but there is all the same a marginalization of “dissent” and a greying of the landscape. The British Journal of Psychiatry has become exceedingly grey – although its current edition has an opinion piece by Pat Bracken and colleagues.

Twenty-five years ago friends from North America thought Britain was in decline. They remarked how the country couldn’t even afford to mow the grass that grew on the verges of or in the central reservations of motorways. The place was looking scruffy.

No, no I told them it’s a really clever idea. The country was being so intensively cultivated elsewhere that there was a real risk of a loss of biodiversity and letting strips of meadow flourish in the margins of motorways was a creative use of this land. Most of them I’m sure didn’t believe me – some of them I know didn’t.

Britain still has flourishing meadow grasses and plants along its motorways, but its academia it seems cannot allow anything slightly “wild” to grow in the interstices of their journals.

This is at a time when the editors of major British journals in particular see fit to use their journals as a pulpit to pontificate (offer their personal non-consensus views) on issues, while at the same time increasingly denying other voices.

Perhaps we should give up the pretense that this is a Collegial Journal, a journal for Fellows and Members. Where’s the collegiality in getting missives from nameless Editors relayed through someone even though she was quite delightful.

The current Editor in Chief started his term of office by saying he was proud that the British Journal of Psychiatry published articles like that by Healy and Cattell on Ghostwriting in Medical Journals. While the current edition has a call to action by Bracken and colleagues, it also has one by Arthur Kleinman that refers to the need for a Global Mental Health movement. This is certainly a well-intentioned piece but probably offers one of the best examples there is of the capture of evidence-based-medicine by the pharmaceutical industry of which more in the New Year.

It was the “Merry Christmas” what did it.

Share this:

Comments

The BJP may very well be moribund although, in my opinion, it’s not the only such journal to be in its death throes. The correspondence quoted points up what appears to be the fundamental problem in psychiatry and the potential end of psychiatric literature, or, at least, any worth reading. The question for every physician asked to treat a patient who complains of fever, rash, headache, nausea, pain etc. etc. is: “What is the cause of these signs/symptoms?” Without an answer, one can try only to treat the symptoms – band- aiding if you will, while the patient may be worsening or dying.
Given the apparently complete lack of agreement on the cause(s) of psychiatric disorders, how can they be treated effectively? There is not even agreement on the nature, even the existence of “depression”, a term used far too loosely and covering everything from suicide to grief over the death of someone close or simply feeling “blue” in response to some of life’s slings and arrows. We are left, therefore, in a psychiatric quandary, forced to face the situation that every physician knows but psychiatrists increasingly avoid like a plague: acknowledging that it is impossible to treat something appropriately if you don’t know its cause. And heaven forfend that we should admit that sometimes the best medicine is no medicine.

You go with cats.
I go with the The Curious Case of the Dog in the Night Time……
A book everyone should read. A boy lost, but no drugs……………………………………
Am I allowed to say, you have allowed me to say a lot of things, that you might think about removing yourself from this constant argument about what journals want and what you want to say…..

It doesn’t matter. Journals are not important. As you say, who reads them anyway.

I would prefer you to gain a masters degree in media and start employing a media spokesperson for Rxisk.

If you want to really get this wholly absurd mess of pharmaceutical invention off, and gone, have you considered a career change?

Well, they still don’t want to hear that antidepressants may cause such adverse effects that they can be fatal. You’ve been repeating this for only 13 years. Perhaps they thought you’d come around by now.

Maybe scientific journals are going the way of newspapers. Come to think on it, they seem to be emulating newspapers lately. There is much preoccupation nowadays in the editorial suite with branding, frivolous publicity, and image. Even highly regarded journals like Nature can be called out on such issues. See here, for instance: http://tinyurl.com/co4zrom.

Nowhere does preoccupation with image loom larger than with the issue of citations and impact factor. I am not alone in having been asked by a journal editor to revise a submission in order to add in more citations of the journal itself: a purely cosmetic exercise, with no basis in quality.

Several times I have heard back from journals (Archives of General Psychiatry, Neuropsychopharmacology) to the effect that I send them an annoying number of critical letters-to-editor. These editors don’t seem to understand that my critiques are driven by the poor quality of editing and reviewing on display by their own publications.

If it is any consolation, Archives of General Psychiatry, the supposedly premier journal on this side of the pond has not distinguished itself lately, either. Along with several other stakeholders, I have recently been through a bizarre interaction with the editor of AGP. We critiqued deeply flawed current reports in AGP about a major topic – risks and benefits of antidepressant drug use in depressed youth. The editor told me that I had no right to expect print publication of my Letter-to-Editor but that he would consent to allowing it to appear in an on-line Comments section that is non-archival. The blogger 1Boringoldman has described this option as the cantina at the end of the galaxy!

My response to the editor of AGP ran to the effect that he was abrogating the scientific values historically associated with that journal. Four critical letters-to editor were effectively suppressed by this editor. Naturally, I and the others rejected this option.

The principal argument for our refusing this second class offer is that the critiques will not be available in the evidence base for future clinicians who wish to make optimal treatment decisions for patients. In addition, these valid critiques will not be found by future researchers seeking to evaluate published claims in the medical literature. By that means, error is propagated and the self correcting function of science is disabled.

In effect, the editor of AGP trashed the process of scientific criticism and debate in his journal. What once was a vigorous and important section of AGP has now been dumbed down to the ephemeral status of weblog comments. The editor’s specious response to our protest was that by limiting published, on-the-record critiques he could publish more original research reports. The real problem is that AGP blundered by accepting the articles in question. AGP needs to fix the journal’s quality control problem, and the editor needs to take on-the-record responsibility for his blunders. Even the parent journal JAMA has a vigorous correspondence section.After this runaround, imagine my surprise when months later I received a curt communication from AGP saying that my critique will be published after all (look for it in the January 2013 issue). There was no explanation for the change of decision. Our best understanding is that the grownups at JAMA prevailed over the AGP editor’s preoccupation with image.

So, David, you are not alone in your perplexity about the behavior of journal editors. Best regards, Barney Carroll.

i am happy to hear you, David Healy are still telling it like it is, speaking truth to ‘power’ or at least the journals you might expect ‘power’ to be reading.

my eternal frustration is that these drugs are still being pushed on almost anyone who is experiencing mental distress of many kinds. i have managed without medications for many years, not many people’s choice but then most people do not know it can be an option even for the ‘severe and enduring’ illnesses of psychiatric diagnosis.

i just wish that we, as a group of people suffering distress/trauma response which is clearly disruptive to our lives, would be given the chance, and the correct information to make real choices, about our health care. that we would be given the basic human right of being free to find out for ourselves what medicines we are being pressurised strongly to take without question.

having attended a meeting held at the WHO in Geneva some years, ago bringing together a globally representative group of psychiatrists, patients and carers to discuss working out an international ‘best practice’ approach to act as a gold standard all could aspire to, it became clear early on in the presentations that the developing countries were crying out for medicines. the very medicines which i and others from the ‘developed’ world were fighting to escape and be free from being forcibly medicated with.

i fear, much like toxic chemicals once used on our farm produce, tobacco, and now medications of all kinds, as the west slowly wakes up to the harm being done to us in the name of profit and under cover of big business obfuscation, the developing world is to now suffer the exact same exploitations, harms and abuses, for the fat rich to become more fat and rich.

i for one intend to do all i can to speak out against the over use of medications that are now so conclusively proven to be far more dangerous than they could ever be helpful, particularly in long term use.

That is ridiculous … what the hell use is a 100-word Conventional Wisdom Statement? (And by the way I thought Brits wished you Happy Christmas. Have they contracted out editorial work to the Land of the Unfree?)

I am wondering if the decline in guts, and brains, at this journal is just catching up (or catching down) to the brain-lock gripping the readership in the field? Last summer the BJP printed a call for “patient choice” when it came to taking or not taking antipsychotic drugs. The authors also urged doctors to talk honestly with patients about the limited benefits and many serious side effects of these drugs, rather than hyping them mindlessly. Finally, they encouraged readers to respond – particularly patients or “service users”.

In the first few weeks they published thirteen letters – five from “service users” and eight from miscellaneous professionals, mainly psychologists. All voted for patient choice, generally with both hands. One offered a caution, however: Fiona Lobban, a psychologist from Lancaster University, pointed out the terrific articles already written, and even decent NICE guidelines established, to rein in overuse of medication for patients with mild depression. Yet the prescribing caravan had not even slowed down, and precious few patients were being talked to honestly about their options.

We needed a strategy, she said, to insure that our excellent statements around patient choice did not end up by the side of the road again this time. I thought her worries were well founded. After all, this was the British Journal of, um, Psychiatry, right? Yet so far we hadn’t heard from one psychiatrist.

Six weeks later, BJP published three letters from psychiatrists. One wrote to defend the use of antipsychotics – from Sri Lanka. (Actually he seemed to be saying only that they were terribly short of resources, and without drugs they’d have nothing.) One Irish doctor agreed with the editorial’s critique, but feared patients would be abandoned to direct marketing by Big Pharma. And one British psychiatrist – a sturdy nonconformist named Bob Johnson, self-employed on the Isle of Wight – wrote in solidarity with patient choice.

Not a single British psychiatrist (or American, Irish, Aussie or Canadian) stepped forward to defend the current system. And yet it rolls on. Like a colleague who stares at his smartphone while you’re trying to talk, the message sent by psychiatry was that they didn’t give a damn about the noises made by “service users”, or even by psychologists. Even a hysterical NAMI-type lecture about patients who can’t grasp their own interests would have been a better omen than that silence. We don’t defend these things, it seemed to say. We don’t talk about them if we can help it. We just do them.

One has to wonder about the effects on treatment if the following were to become common i.e. placing blame on the prescribing physician:
A French psychiatrist has been found guilty of manslaughter after a patient with paranoid schizophrenia hacked an elderly man to death, in the first case of its kind in France.
Danielle Canarelli, 58, was convicted of “involuntary homicide” and given a one year suspended prison sentence over the death of 83 year old Germain Trabuc in March 2004.
A court in Marseille said that Canarelli, who has 30 years’ experience, committed a “grave error” in failing to recognise the risk.

Just to leave something encouraging for the new year … this statement of about 100 words was sent to the BJP by Stewart Herring, a “service user” in Scotland. Many people have tried to expIain what can be hiding behind a twelve-week rating-scale success in a clinical trial. I thought Mr. Herring nailed it.

“The patient on antipsychotic injections had been out of hospital a couple of years, a success from the viewpoint of the medical profession. However in the community a different picture emerges. ‘You’re walkin awfie slow’ said the old lady up the road, ‘ur ye no oot joggin?’ asked the dustbin man and the minister enquired ‘are you not on your bike?. The physicist who worked in the patent office in London was surprised that I wasn’t doing any maths, and amazed that I didn’t care. From personal experience and that of others (‘All you need to know’ drug survey by SAMH) antipsychotic injections deprive us of qualities that define us as human beings and individuals. As someone with over thirty years experience of taking psychiatric drugs including oral and injected antipsychotics my answer to ‘is it time to introduce patient choice?’ is an unequivocal yes.”

As a pharmacist suffering from B12 Deficiency, I became I member of the international charity, Pernicious Anaemia Society, where I quickly realized I was not the first nor the last member to be offered antidepressants instead of B12 by my GP. It was only after 5 1/2 years of contant pain, worsening neuropychiatric symptoms and being unable to work that I gave in and took the fluoxetine offered by my GP. Luckily one month later I discovered that all my symptoms were explained by B12 deficiency and the serum B12 test used to rule it out 5 /12 years previous was very unreliable and definitely not a gold standard test! I was able to purchase injectable cyanocobalamin in Canada without a prescription so I was able to treat myself as my doctor would still not even consider the possibility. I stopped the fluoxetine and started the B12 and 5mg folic acid daily. I had already been taking a B Complex for six months and cyanocobalamin 500-1000mcg tablets for one month. Within days most of my symptoms were gone. Today after ten months of self-treatment I am left with fatigue, peripheral neuropathy and tinnitus. If my GP had order two other tests, MMA and tHcy, along with the serum B12 I am sure my life would be very different right now. Oh and folate is not measured in my province unless you are pregnant so I was not able to find out my level even when it was asked for by my neurologist. I am sure you know that an optimal level of folate is required for Vitamin B12. Why are vitamin deficiencies still not taken seriously by the medical community when study after study shows how important folate and Vitamin B12 are in depression and anxiety? Why are antidepressants handed out like candy when the patient is clearly B12 deficient and not being treated or being undertreated? Is is all down to money? If anyone would like to see how often this really does occur just have a read of the My Story section of the Pernicious Anaemia Society forum. Keep up the good work Dr. Healy! I will be sharing RxISK.org with my pharmacist colleagues.

I also believe I was prescribed Paxil for B12 deficiency; I was 54 and had been taking Zantac for a couple of years. I also believe underlying B12 deficiency set me up for severe and prolonged withdrawal syndrome off Paxil. In the midst of severe withdrawal syndrome, B12 shots brought marked relief, but only slightly blunted symptoms.

1984 is a novel by George Orwell, written on Jura, Argyll, Scotland in 1949.

The Ministry of Love oversees torture and brainwashing.
The Ministry of Plenty oversees shortage and famine.
The Ministry of Peace oversees war and atrocity.
The Ministry of Truth oversees propoganda and historial revisionism.

The protagonist, Winston Smith, works in the Ministry of Truth, as an editor, revising historical records to make the past conform to the ever changing party line and deleting references to ‘unpersons’, people who have been vaporised i.e. not only killed by the state, but denied existence even in history or memory.

Room 101, the most feared room in the Ministry of Love, was where Winston was sent and where he faced a faceful of rats.

At tortures end, upon accepting the doctrine of the party, Winston, now loves Big Brother and is reintegrated into society………..

Canadian orthomolecular psychiatrist Abram Hoffer (1917-2009) had the right idea a few years back when, two weeks before his death, he summed up a one-hour radio interview with: “All psychiatrists should be exported to Mars. We’d be better off without them and they’d be happier without us.” My sentiments exactly. I arranged for intuitive/author/broadcaster Eva Herr to interview Dr.Hoffer.

Abram Hoffer commented: “How can something that makes well people sick, make sick people well?” He treated more than 5000 schizophrenics with inexpensive micronutrients and not pharmaceuticals. “What are you going to do when you are well?” was his first question. Invariably the patients broke into tears. Hope. They got the idea that they could get well and most of them did. For this, Dr. Hoffer was attacked relentlessly by the medical profession for half a century.

Ralph Waldo Trine (1866-1958) writes about the practice of medicine in his 1908 book ‘In Tune With the Infinite’: “A physician goes to see a patient. He gives no medicine this morning. Yet the very fact of his going makes the patient better. He has carried with him the spirit of health; he has carried brightness of tone and disposition; he has carried hope into the sick chamber; he has left it there. In fact, the very hope and cheer he has carried with him has taken hold of and has had a subtle but powerful influence upon the mind of the patient; and this mental condition imparted by the physician has in turn its effects upon the patient’s body, and so through the instrumentality of this mental suggestion the healing goes on.”

“The method that has as its work the application of drugs, medicines and external agencies is the artificial method. The only thing that any drug or any medication can do is to remove obstruction, that the life forces may have simply a better chance to do their work. The real healing process must be performed by the operation of the life forces within.”

“For generations past the most important influence, the life principle itself, has remained an unconsidered element in the medical profession, and the almost exclusive drift of its studies and remedial paraphernalia has been confined to the action of matter over mind. This has seriously interfered with the evolutionary tendencies of the doctors themselves, and consequently the psychic factor in professional life is still in a rudimentary or comparatively undeveloped state.”

In the words of Henry Bauer (1931) Professor Emeritus/Dean Emeritus at Virginia Tech: “When it comes to science, including medical science, history might even suggest that what ‘everyone knows’ at any given time turns out later to have been wrong to some degree. Scientific understanding has progressed after all, and it has progressed by overturning earlier theories. But even as it’s widely recognized that science has progressed, it’s usually forgotten that this very progress has often meant superseding or rejecting earlier ideas. And the notion that a contemporary consensus might be wrong seems unbelievable to most people.”